A Contract Management Framework to Support A Guide to Commissioning for Community Care

Transcription

1 Contract Management Framework Committee Report - Appendix 1 A Contract Management Framework to Support A Guide to Commissioning for Community Care In Moray we will monitor what matters and use the information collected to improve services Page 1 of 42 Version 1 November 2012 Commissioning and Performance Team

2 Contents 1 Introduction Purpose Principles of contract management Managing the contract Managing the relationship between the Council and Provider Managing any care failures Reviewing the service Reviewing the Contract Management Framework... 7 Appendix 1a Contract Monitoring and review process... 8 Appendix 1b Care deficiencies process and handling complaints... 9 Appendix 2 Assessing contract monitoring level Risk Assessment Table Appendix 3 Contract Monitoring Return Appendix 4 Care Deficiencies Procedure Appendix 4A Moratorium imposed by Council Process, timescales and responsible persons. 33 Appendix 4B Moratorium imposed by Council Appendix 5 Service Review Procedures Appendix 6 - Consultation Page 2 of 42

3 1 Introduction 2 Purpose A monitoring framework was developed as part of A Guide to Commissioning for Community Care and is an essential part of making sure that people get the services they need and contributes to future commissioning and contract processes. This framework follows on from that original document and provides more detail. This framework was originally devised by North Ayrshire Council who kindly allowed us to adapt it to meet the needs of the Moray Council. This framework continues to be based on best practice as outlined in Scottish Procurement Directorate guidelines, The Procurement Journey. ( The award of a contract or framework agreement is not the end of the process, but the beginning of ensuring that effective services are delivered to support service users. The purpose of contract management is to ensure that services are being delivered in line with service users stated outcomes, Best Value (quality and price), continually meet contract and regulatory requirements and strive for efficiencies and improvements. It is always the providers responsibility to maintain quality assurance systems, which ensures that services are delivered in line with these requirements. Therefore, it is with an emphasis on providers responsibilities, that the contract management framework outlined in this document aims to provide an approach to evidencing the quality and performance of all care and support services, which is as light touch a process as is possible. 3 Principles of contract management Providers can be confident that information which they exchange will be used appropriately for the contract management task, will be supported in their quality assurance efforts and decision making around service improvements. 4 Managing the contract The process of managing the contract is outlined diagrammatically at appendix 2. This shows the link between the original determination of risk to the Council and impact on service users, through allocation of monitoring level, activity and potential outcomes at each level. In more detail the following sections outline how this is achieved. In cases where there are jointly commissioned services there will be agreement between authorities on the lead and if additional information is required by any authority separate arrangements can be made for this to be received. What is the monitoring process? We will use a monitoring risk matrix to help us determine the level of monitoring services require. It includes consideration of the risk to service users/carers, of outcomes failing to be met, financial risk and reputational risk. Providers will be encouraged to self assess their performance against achievement of service users outcomes and this will become a vital part of determining whether services should continue and contracts re-awarded, where this is permitted by contract terms and procurement regulations (the provider s own assessment of the level to which they meet outcomes is featured in the contract monitoring return (Appendix 3) and this will be checked against service users views (as outlined in Page 3 of 42

4 recorded review information on Carefirst and via the Care Plan Review process), carers views and the views of appropriate local authority staff. The Commissioning and Performance Team/Operational Lead Officer will risk score the service using all available information and this will determine the level of contract monitoring applied. Appendix 2 illustrates the contract monitoring level and types of contract monitoring activity that are appropriate to the level of risk, value of contract, regulatory and service user and carer s opinion. Contract value must also be taken into account when assessing the level of monitoring required in order to provide a safe but cost effective process, however, for social care contracts, care quality and service user outcomes must lead in determining the levels of contract activity. Providers will be allocated to one of the following levels: Low where scores are low for all areas as evidenced by external regulator, internal information from care managers and finance evidence no cause for concern and the risk scores are within the range of low monitoring; Medium where there are care deficiencies for more than one individual in a service or a pattern of care deficiencies over a 3 to 6 month period which have not been sufficiently rectified and/or where care inspection scores have reduced over more than one area since the last inspection and where risk scores in relation to knowledge of service, value of contract, level of needs of service users and risk are within the range appropriate to medium level monitoring; High where there have been serious care deficiencies and/or adult protection concerns relating to care provision, or where care inspection scores have reduced over a year to scores of 2 or 1; and or where financial concerns threaten the ongoing sustainability of the service and will potentially require recommissioning of services and where risk assessment scores fall into the scope of high level monitoring. The process of assessing providers capacity to deliver is an ongoing one and therefore requires performance review meetings. There will be as a minimum an annual performance review meeting conducted by Commissioning and Performance Team/Operational Lead Officers, using desktop analysis of returns, care inspectorate reports and service user and carer information. Changes in information e.g. shift in care inspection scores will trigger a reconsideration of the level of risk and thus level of contract monitoring to be applied. What do Commissioning and Performance Team/Operational Lead Officers do at each level of monitoring? If a provider is on a low monitoring status, then monitoring will be mainly desktop scrutiny of available monitoring information. Information from Care inspectorate reports, Carefirst and Care Plan review information relating to the success of the provider in meeting service user outcomes, finance information relating to invoicing arrangements and assessment of the financial health of the organisation will be analysed. If there are no issues relating to the quality of care or the financial sustainability of the provider then a record to that effect will be made in contract files, noting that low monitoring will continue. The provider should be notified by e mail of this decision and feedback on their performance. A provider will be on medium monitoring status if there are care failures for more than one individual in the service or a pattern of care failures and/or if a provider fails to return monitoring information or accounts or if risk assessment of knowledge of the organisation, value of service, level of needs and risk in the service demands. This demands a closer look at the service and in addition to scrutiny of desktop information, the provider should be alerted to the Council s concerns Page 4 of 42

5 in writing, referring to the appropriate sections of the current contract if appropriate, and asked to respond. A meeting should be convened, preferably in the providers premises, which provides an opportunity to speak to service users, staff and managers about the issues of concern. This meeting is key to agreeing that there are issues to be addressed, endorsing the provider s approach to resolving these and jointly agreeing the key performance measures which will be an indicator of service improvement. It is important that there is a quarterly review of these measures to ensure improvement is being made. When there is joint agreement that the issues which gave rise to concern are resolved, the provider should be advised in writing that the Council is satisfied that sufficient progress has been made to cease quarterly visits and return to low level monitoring. It is important that throughout the process contract records are updated and information is shared with providers, Care Officer/Social Workers/managers and service users and carers. In terms of the latter, this is often undertaken by providers through service user and carer meetings and reviews. High monitoring status applies when there has been a care failure or serious incident initiating adult protection investigations, or if the quality of care and support as notified by the care inspectorate has been judged to be unsatisfactory (1) or poor (2) or an improvement notice is served, or the risk assessment scores high in terms of knowledge of service or unregistered service, value of contract, or high level of needs and risk. It is important to recognise that although the Care Inspectorate regulates the quality of the service for all users; it is the specific responsibility of the Council to ensure the safety and wellbeing of the service users for whom we have commissioned or purchased the care. In addition to the actions outlined above, reviews of service users care plans need to take place to ensure that the service is delivering on their outcomes and that the issues which gave cause for concern have not affected them. At the same time, a discussion will take place with the provider on whether referrals to the service should be temporarily stopped to allow the provider time to address the issues of concern. It is preferable that the provider elects to put a voluntary moratorium (where the service stops taking referrals) in place, however, if the Council judges the issues affect service users generally in the service then a decision may be taken to enforce a moratorium. Meetings will be required with the provider to agree the actions to improve services (there may be an action plan in place as required by the care inspectorate). In cases where an improvement notice is in place, it is essential that this work is undertaken jointly with care inspectorate staff and helpful if joint visits can take place at a minimum of 4 weekly. When there is joint agreement that issues are resolved it is recommended that the provider move to medium level monitoring for an agreed period prior to returning to low monitoring status. This will allow assurances regarding the sustainability of the improvements. There are some specific contracts which have a quality award payment for care Inspectorate grades of 3 or above. If grades fall below this, Commissioning and Performance Team/Operational Lead Officers will initiate discussion with services and this may result in the removal of the quality award. To ensure consistency with the care inspectorate view of improvements, if a quality award deduction is not made and the care inspectorate subsequently maintain the low grade or find the action plan improvements unsatisfactory, then the quality award will be withdrawn backdated to the date of the original inspection. Page 5 of 42

6 What will be reported and to whom? Commissioning and Performance Team/Operational Lead Officers are responsible for programming and maintaining the system of contract monitoring. However, agreement to their recommendations is required by the Commissioning and Performance Manager. There is a clear reporting structure via regular Commissioning Meetings with Senior Officers. What financial information is monitored? In addition to managing the contract from a care quality perspective, the Commissioning and Performance Team/Operational Lead Officer s task is also commercial to ensure that variations and exceptions to the original service specification and contract terms are minimised and that services continue to be delivered within the quoted price for service. Working closely with finance colleagues there is also a requirement to ensure that services are sustainable. The provider s financial health will be measured by a combination of annual scrutiny of submitted accounts, use of companies house information for limited companies and reports from social work finance on adherence to invoice procedures. Any issues which arise will be discussed with providers to ensure that contingency plans can be put in place timeously in the event of the potential for insolvency or bankruptcy. Are there other monitoring requirements? Contracts are signed by the Council and provider which set out the terms and conditions under which services will be delivered. Information will be gathered from service users and carers through Carefirst records, Social Services Care Officer/Social Workers/Managers, service user and carer forums, Care Inspectorate Inspection reports (this list is not exclusive). This information will inform monitoring status and quarterly review. The information gathered from providers quarterly is the standard common information which will be collected for all contracted services in order to monitor that outcomes are met in line with the quality, cost and service terms and conditions set out in service specifications and contracts. 5 Managing the relationship between the Council and Provider It is important that from the beginning of the contracted relationship there is an open dialogue between the Commissioning and Performance Team/Operational Lead Officers and providers, which will clearly set out the monitoring level to be applied, the reasons for this and the conditions under which this will be changed. As the contract life progresses there will be ongoing feedback to providers on the level of monitoring applied. Group meetings with providers will focus on encouraging best practice in services. 6 Managing any care failures A separate detailed set of procedures is appended (Appendix 6) which outlines the process to be followed, roles and responsibilities of community care staff and impact on providers, in terms of requirements to develop action plans, agree improvement measures and performance measures to indicate that issues are addressed and any financial impact on delivering the contract are also addressed. Page 6 of 42

7 7 Reviewing the service The purpose of service review is to meet the obligations of the contract to have a review process in order to determine whether the contract should continue and to determine: What is going well - is it delivering? What is going wrong - where is corrective action needed? What can be improved - where is service development possible? What the service has delivered - performance/outputs What the effect of the service has been - tangible outcomes In the last year of the contract term a service review will be conducted. This is an opportunity to examine whether the service fits with the Council s objectives for service users and carers, and whether services should: Continue with the same service specification and same level of usage; Continue but with a different service specification (variation) and decreased/increased use; Cease service or contract with provider. It is also an opportunity to identify any improvements that could be made to the care and support arrangements and should involve providers and service users and carers to identify changes as well as the relevant Community Care Officer/Social Worker or Team Manager, where appropriate. At the beginning of the final year of the contract a service review will take place. A service review procedure is outlined at Appendix 5. It is important to recognise that this is not done to but with service providers and must take into account the views of service users and carers who receive the service. The procedure identifies the roles and responsibilities of community care staff and information requirements. The information requirements include a review of the performance objectives, the performance of the service against these, usage of the service, quality and cost. These are part of regular contract monitoring requirements therefore the review should not require additional information from providers but be based on collated information from the contract monitoring process. The conclusion of the service review should result in: A decision to maintain, vary or cease services An action plan for improvements Identification of any efficiencies which could be made. These should be set out in an action plan with agreed actions, responsibilities and timescales. If a significant change is proposed then the Council needs to consider whether the current contract is still appropriate. Under Procurement regulations material changes, e.g. extension beyond the advertised scope of the contract is a new contract and should be advertised and subject to competition. However, the Council holds service users choice as central to the selection and delivery of all services and will seek to support service users to maintain services if that is their choice and their outcomes are being met. This may be through the provision of an individualised budget or direct payment using a Self Directed Support approach to service delivery. 8 Reviewing the Contract Management Framework There will be a review of A Guide to Commissioning for Community Care during the January to March 2014 quarter. The review will include this framework. This will be led by the Commissioning Officers. Thereafter the framework will be reviewed at 3 year intervals to ensure that it remains fit for purpose and does not duplicate any other processes. Page 7 of 42

8 Appendix 1a Contract Monitoring and review process Commissioning and Performance Team/Lead Officer Assesses current performance and assigns monitoring status Low Issue contract Monitoring return Provider completes And returns monitoring form Medium High Issue contract monitoring return request action plan and arrange meeting Return is analysed against other information from Care Inspectorate, service users/carers and care officers Issue contract monitoring return/ request action plan/ arrange meeting and consider compliance action Input outcome to Quarterly Report Return validated Return not validated Discussion with provider And amendment to return Quarterly reports collated and annual report produced identifying issues of concern and best practice/service innovations Annual reports collated and used as a basis for service review, considering whether outcomes met, service volumes delivered, continued strategic fit and relevance to council objectives, cost competitive No service concerns continue service and current contract Service concerns but service redesign capacity and/or market shortage arrange contract variation Service concerns and no service redesign capacity terminate contract and re-commission service Page 8 of 42

9 Appendix 1b Care deficiencies process and handling complaints Review available information and assign contract monitoring level Low Level Services with CI scores of 3 or above and no adverse service review comments recorded no gaps in financial information submitted and no pattern of complaints/ critical incidents. Low risk assessment scores Medium Level Services with CI scores of 2 and/or adverse service review comments recorded and/or gaps in submission of financial information and developing pattern of complaints or critical incidents. Medium risk assessment scores High Level Services with CI scores of 1. Pattern of adverse Service review comments recorded and/or adult Protection issues. Pattern of complaints and critical incidents and/or high Risk assessment scores. Activity Desktop monitoring, communication with provider. Inclusion in quarterly Service monitoring. Report to management/ care officers. Activity Desktop monitoring. Communication by letter to provider. Agreed action plan and performance measures. Analysis of recent Review information. Minimum of quarterly visit. Inclusion in quarterly service monitoring. Report to management/ care officers. Activity Desktop monitoring. Communication by letter to provider and agreed action plan/performance measures. Active reviews of carer. Minimum of 4 weekly visits. 4 weekly service monitoring report to senior management/care officers. Potential contract and service review outcome Services maintained with no variation or conditions attached. Potential contract and service review outcome Contract and services maintained if improvements sustained. Potential contract and service review outcome Termination of Existing contract and Commissioning of Alternative services Page 9 of 42

10 Appendix 2 Assessing contract monitoring level Risk Assessment Table Criteria Organisation Quality of Infrastructure Management & Staffing Local service; well established and known to the department as well organised service. Score National organisation; experienced in service field. Competent management and well trained staff. Out of area but known, or local service, not well established but known Out of area and not known, or local service, not well established and not known Local service; known to be of concern to other authorities or with poor Care Inspectorate grades Competent management No real knowledge of but largely untrained staff. management. Recent change in local management but competent regional management Weaknesses in management or staffing identified. Terms Annual Spend Under 100k 100k - 200k 200k - 500k 500k - 750k 750k + Monitor Risk Service Specification/ Contract Position Evidence form routine monitoring Care Inspections Grades Service Type/Client Risk Contract / Specification in place, but needs updated. Contract/Specification in place with outlines service requirements and obligations of provider. Monitoring findings from range of sources positive. Contract / Specification in place but problematic working relationship evident. No contract or specification in place, but established positive service relationship evident. No contract or service specification in place and no substantial service history evident Limited monitoring but No monitoring but Monitoring arrangements findings positive. positive track record. still to be established. Care inspection scores of 6 for care and support staffing, management and leadership. Care inspection scores of 5 for care and support and staffing, management. Care inspection scores of 4 for care and support and staffing, management and leadership. Care inspection scores of 3 for care and support and staffing, management and leadership or new registration. Monitoring identifies complaints and concerns re service. Care inspection scores of 2 or Support and / or advice only. Low levels of personal care and clients able to selfadvocate. Low levels of personal care and clients unable to self-advocate. High level of personal care provided in group living setting. High level of personal care provided in client s home. Fit Strategic Fit Service clearly fits with Service in process of Departmental strategies. modernising. Standards of delivery satisfactory, but service model dated. Service model dated and provider reluctant/unable to change and modernise. Standards of delivery unsatisfactory and service model dated. Page 10 of 42

11 Finance Financial Assessment Service viable, accounts submitted and operating within financial parameters. Service not subject to financial review in past 2 years but accounts available and operating within financial framework set. Service has occasional difficulties in operating within financial frameworks and gaps in submission of financial accounts. Service has repeated difficulties in operating within financial frameworks and accounts not submitted. Service subject to concerns about financial viability of organisation, no accounts submitted since contract awarded and/or key indicators of concern. Note: As a general principal scores in the range 8 to 28 should be considered low monitoring (since high levels of personal care supplied and/or high value are not in themselves a risk only in combination with other factors), 29 to 34 medium and 35 to 40 high. Page 11 of 42

12 Appendix 3 Contract Monitoring Return Contract Monitoring Return The Moray Council Date reporting from/to: Provider Details: Contract Details Provider name: Contract Ref: (If known) Service name: No. of actual service users attending for this quarter Main Service type: Completed by: (registered manager name) No. of voids for this quarter No. of registered service users for this quarter Contract value or rate Contract Review date (Registered Capacity) (State per hour/ day/week/4 week) Contact Number: Care Inspectorate Grades: Care and support Page 12 of 42 Management and Leadership Date of most recent Inspection:

13 Date of completion: Staffing Environment Key Performance indicators 1 Service User Outcomes Independence Involvement Security Confidence 2 Quality Service User Reviews Service User Satisfaction Continual Improvement/Innovation 3 Service Complaints and compliments Incidents Contract Information Qualifications and training Staffing levels 4 Cost Invoice Accuracy Efficiency Initiatives Financial viability Self assessment Comments Note: comments should always be provided if you have self assessed unsatisfactory or very good Overall comments (if you have had voids for this quarter please tell us why you think this is - Page 13 of 42

14 illness, lack of referral etc:: This return has 4 sections. Each section focuses on a different aspect of key contract information and asks for some basic information, self assessment and has specific guidance on completion. Please save your first return and then amend for subsequent returns. This will reduce the time to complete. This information will be used to determine the level of contract monitoring appropriate to the service and for service reviews to determine whether contracts should continue or be re-awarded. You should always use the comments section if you have self assessed unsatisfactory or very good and e mail supporting information. Your input to developing this return is vital and we will be inviting feedback and reviewing this with you after the first year of operation. Page 14 of 42

15 Key Contract Information from your management information systems How many Moray Council service users have been asked their opinion for this return? How did you ask service users? (Choose from - care plan review, questionnaire, focus group, other - please advise) How many of these service users required assistance to express a view (e.g. through family members, advocacy services) Who helped the service user express their views? (family member, other carer, advocacy service, care staff) What % of users is this? Self Assessment Key Performance Area Performance Criteria Indicators Unsatisfactory Adequate Good Very good Good Quality of Life Defined as the Service User feeling valued, being able to decide on day to day matters, having influence and making choices Less than half of the people in the service asked advised that the service met these outcomes. Half (at least 50%) of people in the service said that the service helped them to meet most of these outcomes Three quarters (75%) of people in the service said that the service helped them meet almost all of these outcomes. Almost all (95% or above) people in the service said that the service helped them meet all these outcomes. Outcomes Independence Defined as the Service User being part of the decision making process, having an input into day to day activities, making choices and encouraged to maximise their independence Less than half of the people in the service asked advised that the service met these outcomes. Half (at least 50%) of people in the service said that the service helped them to meet most of these outcomes Three quarters (75%) of people in the service said that the service helped them meet almost all of these outcomes. Almost all (95% or above) people in the service said that the service helped them meet all these outcomes. Involvement Defined as the Service User being informed and enabled to influence the way in which care is provided in a flexible and appropriate way. Less than half of the people in the service asked advised that the service met these outcomes. Half (at least 50%) of people in the service said that the service helped them to meet most of these outcomes Three quarters (75%) of people in the service said that the service helped them meet almost all of these outcomes. Almost all (95% or above) people in the service said that the service helped them meet all these outcomes. Page 15 of 42

16 Security Defined as the Service User being confident that care/support is provided in a manner which ensures their well being Less than half of the people in the service asked advised that the service met these outcomes. Half (at least 50%) of people in the service said that the service helped them to meet most of these outcomes Three quarters (75%) of people in the service said that the service helped them meet almost all of these outcomes. Almost all (95% or above) people in the service said that the service helped them meet all these outcomes. Confidence Defined as the Service User feeling certain that the care/support is received from know and trusted people whose allocation is managed and trusted. Less than half of the people in the service asked advised that the service met these outcomes. Half (at least 50%) of people in the service said that the service helped them to meet most of these outcomes Three quarters (75%) of people in the service said that the service helped them meet almost all of these outcomes. Almost all (95% or above) people in the service said that the service helped them meet all these outcomes. Guidance on completion Please answer the questions at the top at the date of completion of this return, which lets you tell us how many people have been asked their opinion about whether their outcomes were met in this return. It is expected that over the course of one year (4 returns) all people in the service from Moray Council will have been asked. It is appreciated that some people may find it difficult to express a view and in this case you are asked to identify how many people required assistance and who helped them. All assessments and reviews will focus on the outcomes that people want from the service and therefore asking people who use the service is vital to establishing whether it meets their needs. Please see the 'Information on Outcomes' section which gives more detail on how the outcomes can be met. Note that not all will be relevant to the service you deliver. Page 16 of 42

17 Key Contract Information from your operational records and management information systems Reviews How many service user reviews have been held this quarter? How many have had social work input? Customer Satisfaction surveys How frequent are your customer satisfaction surveys? What format do you use, e.g. focus groups? What areas have been surveyed? Self Assessment Key Performance Area Quality Performance Criteria Reviews Satisfaction Indicators Unsatisfactory Adequate Good Very good Reviews are regularly undertaken by you to ensure that services are still meeting outcomes, are recorded and information routinely shared with service user, family and social work. Customer satisfaction surveys are regularly undertaken by you (in addition to reviews) around specific service areas, e.g. quality of food, environment, care provided, social activities, and these are used to improve services to people. Reviews do not take place timeously, do not focus on outcomes, are not recorded fully and no information is routinely shared. No customer satisfaction surveys take place. Reviews take place timeously and are recorded, but are not outcomes focused, and information is sometimes shared with some of the people referenced. Customer satisfaction surveys take place but are not regular and outcomes do not always feed through to improvements in service. Reviews take place timeously, are outcome focused and recorded but information is not shared routinely with all parties. Customer satisfaction surveys regularly take place and outcomes feed through into improvements in service. All indicators are met and outcomes collated into potential areas for improvement or satisfaction surveys. Information is shared will all parties. Customer satisfaction surveys regularly take place and outcomes feed through into improvements in service and are shared with other services and acknowledged in best practice literature and research for that particular care group Page 17 of 42

18 or service. Continual Improvement Provider regularly researches best practice e.g. managing dementia, mental health issues, falls management, service specific improvement and introduces into the service by consulting with staff and service users and providing appropriate training, sharing this with all stakeholders and with other providers and contributing to research. No research is undertaken and no innovative practices are introduced into service. Best practice is identified and training provided but there is no implementation plan to ensure that change is sustained, and no sharing with others. Best practice is identified, introduced through training and consultation and shared with service users but not shared with other providers or contributes to learning elsewhere. All indicators are met and the provider is acknowledged in best practice literature and research for that particular care group or service. Guidance on completion Providers should complete the number of reviews and satisfaction surveys for the quarter and identify which areas have been surveyed in this period. (Please note these are your in-house service reviews). The self assessment then asks for an objective view of whether these have fed through into service improvements and contributed to best practice across the sector. Learning organisations seek to use practice and research together to improve services and the last section lets you demonstrate the extent to which you are a learning organisation. This helps us identify organisations which could improve performance across all contracted services and lead workshops at provider forum meetings. Page 18 of 42

19 Key Contract Information from your operational records - (in the reporting quarter prior to this return) Complaints, Compliments and Incidents (please continue to use and send us the monthly or quarterly return which records details) How many compliments did you receive? How many complaints have you received in the reporting quarter prior to this return? How many were resolved to the satisfaction of the After investigating how many complaints were upheld? service user? How many incidents have you recorded in the reporting quarter prior to this return? Training and qualifications How many staff are permanently employed in your service at the date of this return? How many staff are listed on your registration staffing schedule? If these two figures are different, how do you cover gaps in service provision e.g. agency, overtime hours? What percentage of your staff have qualifications appropriate to their role at the date of this return? What percentage of your staff do you plan to have qualified by the time of the next return? How many staff have received training in the reporting quarter prior to the date of this return? What type of training have they received? (includes any permanent bank staff). What % of your care staff is this? How many staff have left your organisation in the reporting quarter? How many staff have you employed in the reporting quarter? Total number of staff employed in the reporting quarter? Page 19 of 42

20 Key Performance Area Service Performance Criteria Complaints and compliments Incidents Contract information Key Indicators Unsatisfactory Adequate Good Very good There is a complaints and compliments system, which identifies informal from formal complaints, records outcome of investigations, takes appropriate action and shares outcome with service user, families carers and social work. Trends are identified and become areas for improvement at system level leading to changes in policy or staff training. There is an incidents system, which identifies and records outcome of incidents, takes appropriate action and shares outcome with service user, families carers and social work. Trends are identified and become areas for improvement at system level leading to changes in policy or staff training. Contract information (see checklist under) is provided in the agreed format and within the agreed timelines. There is no complaints or compliments system or there is a system but no separation of formal from informal and no record of discussion or action taken. There is no incident system or there is a system but no record of discussion or action taken. No or partial information is provided or information is provided only after the Council intimates the potential for enforcement action if not received. Page 20 of 42 There is a complaints and compliments system which identifies formal complaints and investigates, but outcomes are not always shared and there is limited feed through into service improvement. There is an incidents system which identifies and investigates, but outcomes are not always shared and there is limited feed through into service improvement. Information is provided but is often out with timescales. There is a complaints and compliments system which identifies formal complaints, investigates and takes action and shares outcomes with all relevant parties. However there is limited trend analysis. There is an incident system which identifies, investigates and takes action and shares outcomes with all relevant parties. However there is limited trend analysis. All information is provided and is complete and within timescales. There is a complaints and compliments system which identifies formal complaints, investigates and takes action and shares outcomes with all relevant parties. There is good trend analysis. There is an incident system which identifies, investigates and takes action and shares outcomes with all relevant parties. There is good trend analysis. All indicators are met and the provider from time to time initiates discussion over aspects of the information returned in order to improve service.

21 Qualifications Training Staffing Suitably qualified staff are provided which meet SSSC registration requirements/care commission staffing schedule/contract specification/job descriptions and service user needs. Suitably trained staff to meet SSSC requirements/care commission requirements/contract specification/job descriptions and service user needs. There is a regular training audit to establish any competency gaps, and evidence of investment in training in order to meet required training levels. Staff turnover is at a minimal and service is not disrupted Some staff are qualified but insufficient to meet service requirements and with no plan in place to address this. There is some ad hoc training provided but often following some incident rather than part of a planned process. There is a high level of staff leaving the service and service is majorly disrupted. Not all staff are qualified to meet requirements (or planned requirements) but there is a plan in place to address this. There is regular training although not linked to identification of staff competence and with no audit that practice has changed as a consequence. Investment in training is minimal. There is a low level of staff leaving the service and service is sometimes disrupted. Staff are qualified to meet requirements and there is a plan in place to sustain this when new staff join the organisation. There is a training plan for the delivery of regular training which is linked to staff competence directly. Investment in training is good. There is a low level of staffing turnaround and service is rarely disrupted. All indicators are met and a proportion of the staff are qualified above required standards. There is a significant and constant investment in training. There is a low level of staffing turnaround and normal service is maintained. Guidance on completion: Please complete the information at the top of the form, this will let you demonstrate that you have an active complaints and compliments process and incidents process that enables you to deal effectively and promptly with complaints/incidents and records levels of satisfaction. The self assessment section lets you tell us whether you analyse complaints/incidents, look at trends over a period of time and use improvement areas to discuss with stakeholders how systems can be improved and complaints/incidents in this area reduced. Please continue to return the monthly/quarterly return to us as this provides more detail. Contract information that you are required to submit on an annual basis includes annual accounts, certificates of insurance (public and employers liability), certificate of registration, staffing schedule, care inspectorate reports and action plans and notification of care inspectorate feedback sessions. In time all staff will require to be registered with the SSSC and have appropriate qualifications. The questions above and self assessment let you demonstrate that you are working towards this and that even after staff are qualified there is regular training around the specifics of service user care requirements e.g. dementia training, managing challenging behaviour etc. Page 21 of 42

22 Key Contract Information from your financial systems Cashflow and Transaction analysis (in the last reporting quarter prior to date of return) How many invoices have you submitted? What percentage of invoices have been returned incorrect? What was the main reason advised for the majority of returns? What percentage of invoices have been paid within 28 days of your submission to us? Have you submitted your annual audited accounts to The Moray Council? Key Performance Area Cost Performance Criteria Invoice accuracy Identifying efficiencies Key Indicators Unsatisfactory Adequate Good Very good Invoices are accurate, reflect ordered service and where queries are raised are resolved within 7 days. Where there are multiple invoices of small value the provider promotes opportunities for consolidated invoicing and/or other efficiencies. Invoices are regularly inaccurate and queries are seldom resolved within 7 days. The provider does not identify initiatives which could result in cost reductions being achieved. Invoices provide detailed, accurate information, queries seldom occur but are always resolved within 7 days. The provider responds positively to but never proposes cost reduction initiatives. Invoices provide detailed, accurate information, queries seldom occur but are always resolved within 24 hours. The provider is occasionally proactive in identifying cost reduction initiatives and then implementing these. The provider is proactive in identifying opportunities to improve the invoice process by engaging with the council to clarify service requirements prior to invoicing to reduce error and always resolves any queries within 24hrs. The provider is always proactive in identifying cost reduction initiatives and working with the council to implement these. Page 22 of 42

23 Financial viability Evidencing financial viability of organisation through provision of audited and/or management accounts The provider fails to submit required financial information. The provider submits required financial information on prompt. The provider submits required financial information within the agreed timescales without prompt. The provider submits financial information in the agreed format and within the agreed timescales and additionally provides six monthly expenditure and income returns allowing early identification of any issues arising. Guidance on completion: Invoice accuracy and identifying efficiencies have a crucial role in ensuring that you are paid on time for the services that you deliver and this section is designed to try and identify where things are going wrong that prevent this. Through analysis of this section over the course of a year, the Council hopes to improve the percentage of payments on time to you. You are asked to tell us how many invoices you submitted and how many were returned incorrect, with the main reason for these returns. The section also lets you self assess how quickly you resolve outstanding queries and proactively engage with the Council. The council needs to be aware of any financial health issues for providers in order that we can take appropriate action so you are asked to self assess your record of returning annual accounts (required contract information). Page 23 of 42

24 Service User Outcome: Good Quality Of Life Defined as the Service User feeling valued, being able to decide on day to day matters, having influence and making choices in all aspects of their life. Required Outcomes: Evidence that the Service User: i. leads a fulfilling life ii. is listened to, and takes part in day to day discussions iii. lives safely in their own community and home iv. has physical, mental or emotional needs identified (i.e. sadness or depression) and appropriate assistance sought v. is shown respect and is not subject to any form of discrimination vi. is given the opportunity to follow their cultural and spiritual beliefs. To enable the achievement of the outcomes the Provider must: a) reflect the needs and wishes of the Service User when structuring the service as agreed in the Care Plan b) encourage Staff to build up a relationship of mutual trust and respect with the Service User c) train Staff to recognise and report signs and symptoms of mental and physical ill-health and changes to their conditions d) train Staff about adult protection practice e) have a complaints procedure that has been understood by and shared with the Provider s staff and Service Users f) encourage interaction between the Staff and Service User during the delivery of the service g) have a process in place to alert Care Officers to the need for a review of services. Service User Outcome: Independence Defined as the Service User being part of the decision making process, having an input into day to day activities, making choices and encouraged to maximise their independence. Required Outcomes Evidence that the Service User: i. leads an independent life ii. takes greater control of their life iii. is involved in day to day decisions about the care/support and housing support offered iv. lives independently in their own communities and home; v. experiences and performs useful and meaningful activities with whatever; assistance is required vi. develops and maintains maximum independence. To enable the achievement of the outcomes the Provider must: a) encourage Staff to enable the Service User to be as independent as possible b) Have a policy relating to supporting the independence of clients c) encourage the Service User to develop and maintain their skills and abilities to perform functional and meaningful activities d) encourage the Service User to be involved in agreeing their Care Plan, including where appropriate reducing hours e) make sure that Staff work towards carrying out tasks with the Service User and not for the Service User. Service User Outcome: Involvement Defined as the Service User being informed and enabled to influence the way in which care/support is provided in a flexible and appropriate way. Page 24 of 42

25 Required Outcomes Evidence that the Service User: I. contributes positively to the support planning process II. makes informed choices based on sufficient information about alternatives and implications III. is listened to whether complaining or complimenting the service, or suggesting improvements IV. has minor changes made to his/their care/support in order to meet day-to-day changing needs. To enable the achievement of the outcomes the Provider must: a) make sure that the Service User is able to contribute to, and influence, the content of their Support Plan b) make sure that the Service User receives a copy of the Service User s guide describing services provided c) have a system for assuring the quality of care/support which the Organisation arranges d) have a complaints procedure that has been understood by, and shared with the Provider s Staff, Service Users, their advocate or relatives e) make sure that Staff have the necessary skills and confidence to respond positively to the changing needs of the individual Service User and to advise the Care Officer of the changing need. Service User Outcome: Security Defined as the Service User being confident that care/support is provided in a manner which ensures their safety and well-being. Required Outcomes Evidence that the Service User: I. is introduced to the Service in order to reduce fear and anxiety II. knows what time visits will take place III. is visited at the appointed time IV. knows that their personal information is kept confidential V. knows when and why it is appropriate for their confidential information to be shared VI. knows that keys to their home are stored safely and that the security of their home is not compromised VII. undertakes individual activities that have been risk assessed and are not restricted from valued activities unnecessarily VIII. has trust and respect for members of Staff and confidence in their abilities IX. has confidence that policies and procedures are in place in respect of their safety and that these are understood by staff X. has confidence that staff are aware of probity issues. To enable the achievement of the outcomes the Provider must: a) Provide an introduction to the Service, by a personal visit, except in an emergency situation b) The introductory visit to provide the service user with an introductory pack containing (as a minimum) provider contact numbers, complaints procedure and staffing arrangements and for the provider to assess all necessary health and safety issues c) have a process in place to ensure that the Service User knows in advance about their care/support visit and any changes in their visit (e.g. change of staff or time). Providers must ensure that processes are in place to inform service users of changes in an emergency situation e.g.; home carer/support is sick d) ensure that staff attend to client within thirty minutes of planned visit time e) make sure that the Service User and their property are protected, have policies and procedures that reinforce the Service User's sense of security, and ensure that these are shared with and understood by Staff f) Hold a pass key in a central office and to be used in accordance with Council/Provider procedure g) make sure that the Service User's security code, telephone number(s) and key safe numbers are stored appropriately and shared only on a need-to-know basis h) make sure that staff are easily identified as the Provider s Staff by use of badges/photographs Page 25 of 42